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2025 ICD-10-CM code S82.099E

Open fracture of the patella, type I or II, subsequent encounter with routine healing.

Use a secondary code from Chapter 20 (External causes of morbidity) to indicate the cause of injury unless the T-section code already includes the external cause. An additional code (Z18.-) should be used if there's a retained foreign body.

Medical necessity for using S82.099E is established by the need for follow-up care for an open patella fracture to ensure proper healing, address potential complications, and guide further treatment.

The provider evaluates the healing progress of the open patella fracture. They might assess pain levels, range of motion, any signs of infection, and the overall healing of the wound. Further treatment decisions, such as physical therapy or further immobilization, are based on this evaluation.

In simple words: This code describes a follow-up visit for a broken kneecap (patella) where the bone broke through the skin.It's specifically for open fractures classified as Gustilo Type I or II, meaning the break is relatively clean and there isn't extensive soft tissue damage.This code is used for encounters after the initial treatment, indicating the fracture is healing normally.

Other fracture of unspecified patella, subsequent encounter for open fracture type I or II with routine healing.

Example 1: A patient had an open patella fracture two weeks ago, classified as Gustilo Type II. They return for a follow-up appointment to check on the healing progress and have their dressing changed. This encounter would be coded as S82.099E., A patient had an open patella fracture that was surgically repaired.They are now 6 weeks post-op and attending a follow-up to assess the healing and discuss starting physical therapy.This encounter would be coded as S82.099E assuming routine healing., A patient initially presented with an open patella fracture. They return to the ER two days later for pain management and wound care. As this visit occurs after the initial encounter, and assuming the wound is healing normally, S82.099E is appropriate.

Documentation should include details of the initial injury, type of open fracture (Gustilo classification), treatment provided, progress of wound healing, presence or absence of complications (e.g., infection, delayed healing), and any further treatment plan.

** This code is specifically for subsequent encounters, not the initial treatment. This is to be used for open fractures type I and II with routine healing and should not be used if delayed healing, malunion, or nonunion are present.

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